The Bureau of Insurance (DPFR) and
the Bureau of Medical Services (DHHS) completed a joint triennial examination
of Anthem Blue Cross and Blue Shield of Maine, hereafter "Anthem BCBS",
for compliance with 24-A M.R.S.A., Chapters 56 and 56A, Bureau of Insurance
Rule Chapter 850, and Department of Human Services Rule Chapter 109. This
report represents the finding of State surveyors as of April 4, 2006. Anthem
BCBS scored a "Pass" for this triennial examination. Acknowledgement of cooperation and assistance
extended to the examiners by all Anthem representatives is hereby expressed.
This section highlights the findings associated with the examination
of Anthem:
- Quality Management Program was determined to be in full compliance
with Rule 109.
- Credentialing Program was determined to be in full compliance with
Rule 850.
- Utilization Review Program was determined to be in full compliance
with Rule 850.
Recommendation: For UR 22, “Notice Requirements,”
Anthem’s policy did not include the requirement for a phone number
for obtaining assistance or information, but Anthem is given credit for
this requirement because this number is provided in practice. Anthem is
encouraged to include this requirement in the policy.
- Seven of the eight Grievance and Appeals procedures were determined
to be in full compliance with Rule 850.
Recommendation: GA 4, “Second Level Procedures,”
was found to be in significant compliance; the only requirement not met
was for printed materials in an accessible format when requested by an
enrollee with a visual impairment.
Recommendation: For GA 3, “First Level Non-UR Procedures,”
and GA 4, “Second Level Procedures,” Anthem was given credit
in one area of adverse decision notification requirements: “Notice
of the right to auxiliary telecommunications devices or interpreter services
for covered persons with a hearing impairment or notice of the right to
printed materials in accessible formats for persons with visual impairment”
because Anthem provides TTY information on member identification cards.
Anthem is encouraged to also include this information in its adverse determination
notices.
- Access, Availability, and Continuity of Care policies were determined
to be in full compliance with Rule 850.
Recommendation: For AC 6, “Barriers to Access,”
Anthem was given credit for its literacy strategy, although there was
no documentation, because it was carried out in practice. Anthem is encouraged
to create a written strategy for dealing with literacy barriers.
